Decoding Chronic Venous Obstruction: Introducing a New Classification System for Predicting Treatment Outcomes

Rationale

Chronic venous obstruction (CVO) of the iliofemoral tract and inferior vena cava can cause debilitating symptoms and negatively impact patients’ quality of life. Venoplasty and stent placement have become a low-risk treatment option for symptomatic patients, with varying success rates. To better predict outcomes and guide treatment decisions, the following classification system based on the anatomical extent of CVO is proposed.

Key insights

The classification system consists of 5 categories:

• Type 1. Non-thrombotic iliac vein lesion (NIVL)
• Type 2. CVO of iliac segment
• Type 3. CVO of iliofemoral segment above the confluence of the common femoral vein (CFV)
• Type 4. CVO of iliofemoral segment extending into one of main inflow veins (either the femoral vein (FV) or deep femoral vein (DFV))
  • Type 4a: CVO involving the FV
  • Type 4b: CVO involving the DFV
• Type 5. CVO of iliofemoral segment involving both main inflow veins (DFV and FV)

Based on a large-scale multicenter study, a strong correlation was found between the classification types and stent patency rates at 48 months, with type 1 having the highest patency rate and type 5 having the lowest patency rate. Extension of CVO below the inguinal ligament and the total number of stents were identified as 2 independent risk factors affecting patency rates.

Take-home message

This classification system aims to improve therapeutic decision-making by providing better insights into the anatomical extent of the disease. Here are a few examples of how this classification system can be useful:

1. Selecting optimal candidates for intervention

By identifying the type of CVO, physicians can better determine which patients are most likely to benefit from venoplasty and stent placement. For example, patients with type 1 or type 2 CVO may be more suitable candidates for intervention, as they tend to have higher stent patency rates compared to those with more extensive disease (type 4 or 5).

2. Tailoring treatment approaches

Understanding the extent of disease can help physicians tailor treatment approaches to individual patients. For instance, patients with type 4a or 4b CVO may require a different approach in terms of stent placement or additional interventions, such as hybrid intervention or additional angioplasty of the femoral vein, compared to patients with type 2 or 3 CVO who may have a more straightforward treatment process.

3. Informing patients about potential outcomes

By classifying CVO severity, physicians can provide patients with more accurate information about the expected outcomes and potential risks associated with stent placement. For patients with more severe CVO types who may not benefit as much from stent placement, physicians can use the classification system as a basis for discussing alternative treatment options, such as conservative management with compression therapy and anticoagulation.

4. Monitoring and follow-up

The classification system can serve as a reference point during post-treatment follow-ups. For example, patients with type 4 or 5 CVO may benefit from more frequent Duplex ultrasound examinations or other imaging modalities to assess stent patency and venous flow, allowing for timely intervention, if necessary, while patients with type 1 or 2 CVO might need less frequent imaging.

5. Type and duration of anticoagulation

The classification system can help determine the appropriate duration of anticoagulation therapy following venoplasty and stent placement. Patients with more severe CVO types may require a longer duration of anticoagulation therapy to minimize the risk of thrombosis or stent occlusion, whereas patients with less-severe CVO types might need a shorter or more conservative approach. Furthermore, a patient with a more complex CVO type (eg, type 4 or 5) might benefit from a combined anticoagulant-antiplatelet, while patients with less extensive disease (eg, type 1 or 2) might be suitable for a more conservative antithrombotic strategy.

6. Facilitating communication and research

Consistently using this classification system can improve communication among healthcare professionals and researchers, allowing for more accurate comparisons of treatment outcomes across different studies. This can lead to the development of evidence-based guidelines and a better understanding of CVO treatment options, ultimately benefiting patients.

Summary

This classification system can help identify optimal candidates for intervention, tailor treatment approaches, and inform patients about potential outcomes. Furthermore, it can also aid in monitoring and follow-up, determining the type and duration of anticoagulation, and facilitating communication and research. Ultimately, the consistent use of this classification system can lead to the development of evidence-based guidelines and a deeper understanding of CVO treatment options, benefiting patients and healthcare professionals alike.